Ismail et al.

BMC Cancer (2020) 20:335

https://doi.org/10.1186/s12885-020-06855-9

RESEARCH ARTICLE Open Access

Prevalence and significance of potential

drug-drug interactions among cancer
patients receiving chemotherapy
Mohammad Ismail* , Sehrash Khan, Fahadullah Khan, Sidra Noor, Hira Sajid, Shazia Yar and Irum Rasheed

Abstract
Background: Cancer patients often receive multiple drugs to maximize their therapeutic benefit, treat co-morbidities
and counter the adverse effects of chemotherapy. Concomitant administration of multiple drugs increases the risk of
drug interactions leading to compromised therapeutic efficacy or safety of therapy. The purpose of this study was to
identify the prevalence, levels and predictors of potential drug-drug interactions (pDDIs) among cancer patients.
Methods: Six hundred and 78 patients receiving chemotherapy from two tertiary care hospitals were included in this
cross-sectional study. Patient medication profiles were screened for pDDIs using the Micromedex® database. Logistic
regression analysis was performed to identify the predictors of pDDIs.
Results: The overall prevalence of pDDIs was 78%, majority of patients had 1–2 pDDIs (39.2%). A total of 1843 pDDIs
were detected. Major-pDDIs were most frequent (67.3%) whereas, a significant association of pDDIs was found
between > 7 all prescribed drugs (p < 0.001) and ≥ 3 anti-cancer drugs (p < 0.001). Potential adverse outcomes of these
interactions include reduced therapeutic effectiveness, QT interval prolongation, tendon rupture, bone marrow
suppression and neurotoxicity.
Conclusions: Major finding of this study is the high prevalence of pDDIs signifying the need of strict patient
monitoring for pDDIs among cancer patients. Patients at higher risk to pDDIs include those prescribed with
> 7 any types of drugs or ≥ 3 anticancer drugs. Moreover, list of most frequently identified major and
moderate interactions will aid health care professional in timely identification and prevention of pDDIs.
Keywords: Patient safety, Cancer, Supportive therapy, Potential drug-drug interactions, Polypharmacy

Background Cancer is equally prevalent around the world [3, 5],

The global cancer burden is on the rise due to increased
prevalence of risk factors such as smoking, environmen-
tal pollution, obesity, unhealthy diet, physical inactivity,
infections (hepatitis, helicobacter pylori and human pap-
illoma virus) and use of oral contraceptives [1–4]. The
Global burden of cancer (GLOBOCAN) 2012, reported
an estimated 14.1 million new cases of cancer, which is
anticipated to rise by 70% over the next 20 years [2, 3].
* Correspondence: ismailrph@uop.edu.pk
Department of Pharmacy, University of Peshawar, Peshawar, Khyber
Pakhtunkhwa, Pakistan
however differences in the pattern of cancer and its sub-
sequent therapy exist from region to region [5]. The
overall survival of cancer is high in developed countries
due to timely and easy access to standard health care fa-
cilities [1, 2, 6, 7].
The use of cytotoxic agents is inevitable for the cure of
cancer despite the availability of a number of other alter-
natives such as surgery and radiation [8, 9]. The main
aim of chemotherapy is to cure cancer, extend life years
and improve the overall quality of life [7, 8]. Cytotoxic
agents are often administered in combination containing

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Ismail et al. BMC Cancer (2020) 20:335
two or more cytotoxic drugs as multiple drug regimens
along with other medicines to achieve maximum thera-
peutic benefit and counter the adverse effects of chemo-
therapy or to treat other co-illnesses [10, 11]. However,
interpatient variability is frequently observed especially
with oral cytotoxic agents due to drug interactions as a
result of polypharmacy [12, 13].
Drug-drug interactions (DDIs) are drug combinations
that may result in therapeutic failure or potentially ser-
ious adverse events than from solitary administration
[14–18]. An estimated 2% of hospital admissions are due
to adverse effects caused by DDIs [19, 20] and approxi-
mately 4% of the cancer patients die because of adverse
effects caused by drug interactions [21] however, DDIs
are often predictable and preventable [22, 23]. Advance
age, prolonged hospital stay and increased number of
prescribed medicines are strong predictors of DDIs [24–
27]. The risk of DDIs and its associated adverse events
are higher in cancer patients as they frequently receive
multiple drugs concomitantly [17, 25]. Moreover, there
has been a recent increase in the availability and use of
anticancer agents because of favorable therapeutic out-
come and cost effectiveness [12, 28].
DDIs among cancer patients have been well studied in
developed countries [20, 24, 26–29]. However, such
studies have been poorly addressed in developing coun-
tries like Pakistan. There are a few studies which have
their own scope and limitations such as involving only
QT prolonging DDIs [30], small sample size and differ-
ent drug interactions screening tool [31], and primarily
focused on medication safety [32]. Further, we cannot
generalize the findings of developed countries to the de-
veloping countries because of variations in drug pre-
scribing pattern, utilization of anticancer drugs, pattern
of cancers, drug interactions screening before prescrib-
ing, and non-availability of standard healthcare services.
DDIs involving anticancer drugs are a major concern in
oncology practice due to their potential to cause severe ad-
verse effects [1, 28, 33, 34]. Moreover, knowledge about the
most common interacting drugs used in cancer patients and
identification of predictors of pDDIs are essential to reduce
avoidable drug-related problems and increase the efficacy
and compliance of chemotherapy [14, 17]. Additionally, this
study will be helpful for the promotion of rational drug use
and for the prevention and management of drug interactions
leading to improved therapeutic outcome and patients’ qual-
ity of life [34, 35]. Therefore, the study aimed to identify the
prevalence, levels, predictors and potential adverse outcome
of pDDIs among cancer patients receiving chemotherapy.
Methods
Study settings and design
A cross-sectional study was performed in two tertiary
care hospitals of Peshawar, Khyber Pakhtunkhwa,
Page 2 of 9
Pakistan: Hayatabad Medical Complex (HMC) and
Northwest General Hospital and Research Center
(NWGH & RC). HMC is a public sector tertiary care
teaching hospital whereas, NWGH & RC is a private
sector hospital.
Selection criteria
Patients of any age and either gender diagnosed with any
type of cancer and treated with anticancer agents (either
intravenous and/ or oral) were included in this study.
Whereas, patient profiles were excluded if the required
information were lacking.
Data collection and screening for pDDIs
Data regarding patient’s demographic, symptoms, la-
boratory results and prescribed medications were col-
lected after acquiring written permission from the
administration of respective hospitals.
Micromedex Drug-Reax® (Truven Health Analytics,
Greenwood Village, Colorado, USA) was used for the
screening of patients’ medication profile for pDDIs [36].
We select this software because it has got highest sensi-
tivity and specificity score [37, 38]. Further, it has got
sensitivity score of 70% in identifying drug interactions
involving oral anticancer drugs [39]. According to the
description of this database, all detected interactions
were categorized on the basis of severity-levels and
documentation-levels [36]. All available lab values were
reviewed to identify abnormal results.
Statistical analysis
In statistical analysis, quantitative data were presented as
frequencies and percentages. Logistic regression analysis
was applied in order to identify association of pDDIs
presence with patients’ gender, age, prescribed medica-
tions, hospitalization status, cancer type, presence of me-
tastasis, treatment type and treatment intent. For each
predictor odds ratio (OR) a 95% confidence intervals
(CIs) was determined by performing univariate logistic
regression analysis. For variables with significant univari-
ate p-values multivariate analysis was performed. In this
study p-value of 0.05 or less was considered significant.
SPSS version-23 was used for statistical analysis.
Results
Patients characteristics
Out of total 678 patients, 358 (52.8%) were male and
320 (47.2%) were female. Majority of patients were in
the age range of 41–60 years (29.5%) followed by 21–40
years (26.4%). The use of 7–9 drugs (37.3%) and 10–12
drugs (29.4%) were most frequent. Whereas, majority of
patients (81.9%) were prescribed ≥2 anti-cancer drugs
and ≥ 4 supportive drugs (87.6%) as presented in
Table 1.
Ismail et al. BMC Cancer (2020) 20:335 Page 3 of 9

Table 1 Patient characteristics (N = 678) Table 2 Cancer characteristics and their types
Variables Patients: n (%) Variables Patients: n (%)
Gender Cancer type
Male 358 (52.8) Solid malignancy 360 (53.1)
Female 320 (47.2) Hematologic cancer 318 (46.9)
Age (years) Metastasis
≤ 10 101 (14.9) Present 112 (16.5)
11–20 110 (16.2) Absent 566 (83.5)
21–40 179 (26.4) Treatment intent
41–60 200 (29.5) Curative 620 (91.4)
> 60 88 (13) Palliative 58 (8.6)
All prescribed drugs Type of chemotherapy
≤6 120 (17.7) Cytotoxic agents 508 (74.9)
7–9 253 (37.3) Hormonal agents 4 (0.6)
10–12 199 (29.4) Monoclonal agents 3 (0.4)
13–15 64 (9.4) Combinationa 163 (24)
> 15 42 (6.2) Solid malignancy
Anticancer drugs Gastrointestinal cancer 89 (13.1)
1 123 (18.1) Breast cancer 64 (9.4)
2 264 (38.9) Gynecological cancer 47 (6.9)
3 159 (23.5) Musculoskeletal cancer 42 (6.2)
≥4 132 (19.5) Genitourinary cancer 41 (6)
Supportive care drugs Head and neck cancer 19 (2.8)
≤3 84 (12.4) Neurological cancer 13 (1.9)
4–6 242 (35.7) Respiratory cancer 11 (1.6)
7–9 246 (36.3) Others 34 (5)
≥ 10 106 (15.6) Hematological malignancy
Acute lymphoblastic leukemia 127 (18.7)
Non-Hodgkin lymphoma 117 (17.3)
Cancer profile and treatment of study subjects
Table 2 illustrates cancer profile and its treatment for Acute myelogenous leukemia 28 (4.1)
study subjects. Solid malignancies were most frequent Chronic lymphocytic leukemia 17 (2.5)
among the study participants (53.1%) as compared with Hodgkin lymphoma 18 (2.5)
hematologic malignancies (46.9%). Metastasis was seen Chronic myelogenous leukemia 7 (1)
in 112 (16.5%) patients whereas 620 (91.4%) patients Others 5 (0.7)
were receiving curative treatment. Moreover, the use of
-aCombination means regimen comprising of cytotoxic, hormonal or
cytotoxic agents (74.9%) and combination therapy (24%) monoclonal agents in combination
were common while hormonal or monoclonal agents
were rarely prescribed. The most frequent solid malig-
nancies include gastrointestinal cancer (13.1%), breast patients had 1–2 pDDIs (266), 5–6 pDDIs (100) and 3–4
cancer (9.4%), gynecological cancer (6.9%), musculoskel- pDDIs (93).
etal cancer (6.2%) and genitourinary cancer (6%). Like-
wise, the most frequent hematological malignancies
include acute lymphoblastic leukemia (18.7%), non- Levels of pDDIs
Hodgkin lymphoma (17.3%), and acute myelogenous Overall, 1843 pDDIs were detected, of which, 1240
leukemia (4.1%). (67.3%) were of major and 507 (27.5%) were of moderate
severity while contraindicated pDDIs were least frequent
Prevalence of pDDIs accounting for 25 (1.4%) pDDIs. The documentary evi-
Figure 1 indicates that 529 patients were exposed to at dence of majority of pDDIs were fair (66.4%) and good
least one pDDI (overall prevalence = 78%). Majority of (23.8%) (Fig. 2).
Ismail et al. BMC Cancer (2020) 20:335 Page 4 of 9

Fig. 1 Prevalence of pDDIs. -PDDIs = potential drug-drug interactions. -Overall prevalence means occurrence of pDDIs regardless of severity.
-Percentages do not add up to 78% because many patients were exposed to multiple pDDIs of different severities

Predictors of pDDIs
Table 3 demonstrates the results of univariate and multi-
variate logistic regression analysis for exposure to pDDIs.
Results of univariate logistic regression analysis indicates a
significant relation of pDDIs with all prescribed drugs, an-
ticancer drugs, supportive care drugs, hospitalization, type
of cancer and type of cancer treatment. The odds of
pDDIs are 3.6 times with > 7 all prescribed drugs (p <
0.001), 4.7 times with ≥3 anti-cancer drugs (p < 0.001), 1.9
times with > 3 supportive care drugs (p = 0.001), 1.8 times
with hospitalization (p = 0.004), 2.1 times with combin-
ation treatment (p = 0.003) and 0.4 times with solid malig-
nancy (p < 0.001). Whereas, the risk is insignificant for
gender, age, presence of metastasis and treatment intent.
Likewise, the results of multivariate logistic regression
analysis show a significant relation of pDDIs with the
presence of > 7 all prescribed drugs (p < 0.001) and ≥ 3
anti-cancer drugs (p < 0.001). Whereas, the association

Fig. 2 Levels of pDDIs

Ismail et al. BMC Cancer (2020) 20:335 Page 5 of 9

Table 3 Univariate and multivariate logistic regression analysis

Variables Univariate Multivariate
OR (95% CI) p-value OR (95% CI) p-value
Gender
Male Reference –
Female 0.7 (0.5–1) 0.108 – –
Age (years)
≤ 50 Reference –
> 50 0.8 (0.5–1.2) 0.318 – –
All drugs prescribed
≤7 Reference Reference
>7 3.6 (2.5–5.3) 0.0001 3.5 (2.2–5.5) 0.0001
Anticancer drugs
≤2 Reference Reference
≥3 4.7 (3–7.4) 0.0001 3.6 (2.1–6.2) 0.0001
Supportive care drugs
≤3 Reference Reference
>3 1.9 (1.3–2.9) 0.001 0.6 (0.3–1.2) 0.161
Hospitalization status
Ambulatory Reference Reference
Hospitalized 1.8 (1.2–2.6) 0.004 1.3 (0.8–2) 0.327
Cancer type
Hematological malignancy Reference Reference
Solid malignancy 0.4 (0.3–0.6) 0.0001 0.7 (0.4–1.1) 0.173
Metastasis
Present Reference –
Absent 1.5 (0.9–2.4) 0.07 – –
Treatment type
Cytotoxic agents Reference Reference
Combination drugsa 2.1 (1.3–3.4) 0.003 0.7 (0.4–1.3) 0.343
Treatment intent
Curative Reference –
Palliative 1.6 (0.8–3.3) 0.218 – –
- pDDIs Potential drug–drug interactions; OR Odds ratio; CI Confidence interval
-Hosmer–Lemeshow goodness-of-fit test: p = 0.3
-aCombination means regimen comprising of cytotoxic, hormonal or monoclonal agents in combination

of pDDIs with supportive care drugs (p = 0.2),
hospitalization (p = 0.3), type of cancer (p = 0.2) and type
of treatment (p = 0.3) are insignificant.
Abnormal symptoms and laboratory results
Table 4 presents the abnormal biochemical results and
symptoms among study subjects. Hematological tests
show reduced hemoglobin in majority of patients
(58.7%) whereas, 118 (17.4%) patients were reported
with reduced red blood cell count. Similarly,
leukocytopenia was observed in 96 (14.2%) patients with
decreased neutrophil count in 70 (10.3%) patients, de-
creased lymphocytes in 149 (21.9%) patients and reduced
eosinophils and monocytes in 47 (6.9%) and 372 (54.9%)
patients, respectively. Abnormal high serum creatinine
was reported in 26 (3.8%) patients and 12 (1.8%) patients
had elevated bilirubin level. While among the liver func-
tion tests, 121 (17.8%) patients had elevated ALT levels
and 106 (15.6%) patients had elevated alkaline phosphat-
ase level. Whereas, the most frequently observed
Ismail et al. BMC Cancer (2020) 20:335 Page 6 of 9

Table 4 Abnormal biochemical results and symptoms among Table 4 Abnormal biochemical results and symptoms among
study subjects study subjects (Continued)
Laboratory test Patients: n (%) Laboratory test Patients: n (%)
Hematological tests Shortness of breath 15 (2.2)
Hemoglobin Generalized weakness 11 (1.6)
< 12 g/dL 398 (58.7) Pallor 11(1.6)
Red blood cells Swelling in different body parts 10 (1.5)
< 4 × 106/mm3 118 (17.4) Bleeding from different body parts 9 (1.3)
> 5.5 × 106/mm3 11 (1.6) Loose motions 10 (1.3)
Total leukocyte count Abdominal distension 8 (1.2)
< 4000 /mm3 96 (14.2) Epigastric pain 9 (1.2)
> 11,000 /mm3 145 (21.4) Dysphagia 10 (1.2)
Platelet count Sweating 11 (1.2)
< 150,000 /mm3 138 (20.4) Urinary tract infections 12 (1.2)
> 450,000 /mm3 63 (9.3)
Neutrophils symptoms among the study participants include fever
< 40% 70 (10.3) (12.1%), generalized body ache (9.3%), nausea & vomit-
ing (4.7%), abdominal pain (4.1%) and cough (3.8%).
> 75% 113 (16.7)
Lymphocytes
Wide spread interacting drug combinations
< 20% 149 (21.9) Most frequently detected pDDIs are enlisted in Table 5
> 45% 91 (13.4) along with their severity, documentation levels and po-
Eosinophils tential adverse outcomes. Reduced therapeutic effective-
< 1% 47 (6.9) ness, QT interval prolongation, drug toxicity such as
tendon rupture, bone marrow suppression, seizures,
> 6% 17 (2.5)
serotonin syndrome, neurotoxicity and cardiomyopathy
Monocytes
were the potential adverse outcomes of these interac-
< 6% 372 (54.9) tions. Potential drug-drug interactions involving anti-
> 10% 23 (3.4) cancer agents are enlisted in additional Table 1.
Renal function tests
Serum creatinine Discussion
This study presents the frequency, severity and predic-
> 1.3 mg/dl 26 (3.8)
tors for pDDIs and list of most frequent pDDIs among
Total bilirubin 12 (1.8)
> 1.5 mg/dl
cancer patients undergoing chemotherapy. An overall
78% prevalence of pDDIs is higher in comparison with
Liver function tests
other studies conducted in oncology setting. A study
Alanine aminotransferase from Iran reported 62.8% prevalence of pDDIs in pa-
> 40 U/L 121 (17.8) tients with hematological malignancy [40]. Another
Aspartate aminotransferase study from Netherland reported a prevalence rate of
> 40 U/L 46 (6.8) 46% among patients using oral anticancer drugs [41].
Alkaline phosphatase
Whereas, a study from the United States of America re-
ported 40% prevalence rate of pDDIs [29]. Similarly, the
< 35 U/L 3 (0.4)
prevalence rate of present study is higher in comparison
> 130 U/L 106 (15.6) with studies from other specialties such as internal
Symptoms medicine (52.8%) [25], psychiatry (64.8%) [42], pediatrics
Fever 82 (12.1) (25.8%) [43] and pulmonology (45%) [44]. Such wide-
Generalized body aches 63 (9.3) spread variability in prevalence may be attributed to dif-
Nausea and vomiting 32 (4.7)
ferences in study designs, inclusion and exclusion
criteria, study population & their characteristics, study
Abdominal pain 28 (4.1)
settings, presence or absence of clinical pharmacy ser-
Cough 26 (3.8) vices, prescribing pattern, drugs involving, and high sen-
Anorexia 19 (2.8) sitivity of drug interactions screening databases/sources.
Ismail et al. BMC Cancer (2020) 20:335 Page 7 of 9

Table 5 Most frequent pDDIs among cancer patients

Drug-drug interaction Frequency Severity Evidence Potential adverse outcome
Dexamethasone + Vincristine 228 Major Fair Decreased vincristine plasma concentration.
Doxorubicin + Dexamethasone 164 Major Fair Reduced doxorubicin exposure.
Ondansetron + Prochlorperazine 116 Major Fair Increased risk of QT interval prolongation.
Cyclophosphamide + Doxorubicin 105 Major Fair High risk of cardiomyopathy.
Ciprofloxacin + Dexamethasone 102 Moderate Excellent Increased risk for tendon rupture.
Ciprofloxacin + Ondansetron 89 Major Fair Increased risk of QT interval prolongation.
Ciprofloxacin + Prochlorperazine 83 Major Fair Increased risk of QT interval prolongation.
Cyclophosphamide + Ondansetron 75 Moderate Good Decreased cyclophosphamide systemic exposure.
Allopurinol + Cyclophosphamide 66 Major Good Cyclophosphamide toxicity (bone marrow
suppression, nausea, vomiting).
Metoclopramide + Tramadol 48 Major Fair Increased risk of seizures.
Ciprofloxacin + Doxorubicin 33 Major Fair Increased doxorubicin exposure.
Calcium Chloride + Ciprofloxacin 32 Moderate Good Decreased ciprofloxacin efficacy.
Ondansetron + Tramadol 31 Moderate Excellent Reduced efficacy of tramadol.
Tropisetron + Tramadol 24 Major Fair Increased risk of serotonin syndrome.
Fluorouracil + Leucovorin 23 Moderate Good Increased concentrations of 5-fluorouracil and
fluorouracil toxicity (granulocytopenia, anemia,
thrombocytopenia, stomatitis, vomiting).
Asparaginase + Vincristine 19 Major Fair Increased vincristine exposure causing neurotoxicity.
Cisplatin + Docetaxel 14 Moderate Excellent Increased risk of neuropathy.
Methotrexate + Omeprazole 13 Major Good Increased concentration of methotrexate and its
metabolite and an increased risk of methotrexate toxicity.
Cisplatin + Doxorubicin 11 Major Good Increased risk of Secondary malignancy i.e. secondary leukemia.
Fluconazole + Metronidazole 10 Major Fair Increased risk of QT interval prolongation and arrhythmias.

The high prevalence of pDDIs identified in our study de-
mands thoughtfulness regarding the issue of pDDIs in
cancer patients receiving chemotherapy.
Levels of pDDIs are imperative for healthcare profes-
sionals to evaluate their potential clinical significance
and rationalize the patients’ treatment. All interactions
are not equally harmful, therefore, classification of the
identified interactions into different levels helps in
proper management of these interactions. The more fre-
quent occurrence of major pDDIs is an important find-
ing of this study, necessitating the need of strict
monitoring of patients as these interactions carry higher
potential for causing life threatening adverse reactions.
A study reported similar results in hematological malig-
nancies [40] however, in majority of studies moderate
pDDIs are more frequent [41, 45, 46].
The use of polypharmacy is prevalent among cancer
patients. The significant association of > 7 prescribed
drugs and ≥ 3 anti-cancer drugs with pDDIs in present
study are coherent with other studies both in oncology
setting and other specialties [17, 22, 27, 47]. The pres-
ence of polypharmacy in cancer patients demands the
screening of prescribed medications for timely predic-
tion and prevention or minimization of any unwanted
negative consequences as polypharmacy is inevitable
among cancer patients. The univariate analysis estimated
a significant association of pDDIs with hospitalized pa-
tients, combination chemotherapy and patients having
solid malignancy however, they were insignificant in
multivariate analysis. Moreover, like other studies age,
gender, metastasis and treatment intent had insignificant
association with pDDIs [17, 34, 45] however, few studies
have reported a significant association of pDDIs with
gender, age and type of cancer [28, 34, 48, 49].
List of most frequent pDDIs particularly those of con-
traindicated, major and moderate severity are of utmost
importance for health care providers. It can aid in the
selective screening of pDDIs by overburdened health
care professionals. Such information is needed for health
care professionals to estimate the risk in specific patients
and guide their therapeutic decision making [8]. Patients
at risk of these interactions may be given special atten-
tion and their therapy may be closely monitored for any
potential adverse effect.
There are a few potential limitations of this study. Al-
though, this work explored pharmacoepidemiology of
pDDIs in cancer patients, the exact extent of patient suf-
fering due to these interactions were not studied. The
Ismail et al. BMC Cancer (2020) 20:335
study was conducted only in two hospitals, which is the
second point which may limit the generalizability of this
study. Moreover, only one drug interactions screening
database (Micromedex Drug-Reax®) was used for the
identification of pDDIs, however, other sources are also
available which may not necessarily give the same re-
sults. Further, we have only included hospitalized cancer
patients receiving intravenous and/ or oral anticancer
agents. In hospital settings, mostly intravenous antican-
cer therapy is provided. We don’t include cancer pa-
tients treated in homebased care settings which could
provide a different DDIs pattern due to frequent use of
oral anticancer agents.
Conclusions
This study points out a high prevalence of pDDIs among
cancer patients treated with anti-cancer agents. Majority
of interactions were of major and moderate severity. Pa-
tients with polypharmacy i.e. > 7 all prescribed drugs or ≥
3 anticancer drugs had a significantly increased risk of
pDDIs. Whereas, list of most frequently identified major
and moderate interactions will aid in timely identification,
prevention and management of pDDIs and their adverse
outcome in cancer patients. Moreover, strict patient mon-
itoring is recommended especially in patients with > 7 all
prescribed drugs or ≥ 3 anticancer drugs for timely pre-
vention and/or management of negative clinical outcomes
associated with these interactions particularly those in-
volving cytotoxic drugs.
Supplementa0ry information
Abbreviations
CI: Confidence interval; DDIs: Drug-drug interactions; HMC: Hayatabad
medical complex; NWGH & RC: Northwest general hospital and research
center; OR: Odds ratios; pDDIs: Potential drug-drug interactions
Acknowledgements
We are very thankful for the cooperation of staff and administration of the
hospitals.
Authors’ contributions
All the authors contributed substantially to the work presented in this paper,
read and approved the final version of manuscript. MI designed the research,
contributed substantially with data analysis, results interpretations and
manuscript editing and approval. SK designed all the work under the
supervision of MI, collected, analyzed and interpreted data, did DDIs
screening, drafted the manuscript. FK and SN collected, analyzed and
interpreted data, did DDIs screening and drafted the manuscript. HS, SY, and
IR collected and analyzed data, interpreted results, did DDIs screening and
drafted the manuscript.
Funding
No funding has been taken for this study.
Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.
Page 8 of 9
Ethics approval and consent to participate
Ethical approval was obtained from the Ethical Committee of Department of
Pharmacy, University of Peshawar, Khyber Pakhtunkhwa, Pakistan. This was a
retrospective study, involving data collected from the hospitals, therefore
individual informed consent was not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Received: 11 January 2020 Accepted: 13 April 2020
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